7 PEARL ST - BUILDING INSPECTIONr
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CITY OF SA�EM
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BUILDNO PERMIT APPLICATION FOR: '
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(CIrals whWm wr apply) Rolfe RN001, In 8 atnaat.Deok, Shad, Pa*Oj
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PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROONWAS
TOTHE INSPECTOR OF BUILDINGS:
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AddrM a Phone 7
Amhkaol'a Name
Addlaaa a Phone ( 1
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SON40 UMBER THE Prl "
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT
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PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STaaaT, 31110 FLO011
SALEM,MA 01 B70
TEL (278)745-9595 EXT.360
or UFAX (976) 740-8846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the 'ons of MGL c Pm� 40,S34,I that ea a
aclno�vladge cmditiaa
of BWldinS Pane t N all debris— �the. r'�B conatrnctical. activity
Bovemed by this Building Permit Shall be disposed of in a properly licensed aolid-Wsaba
disposal facility.as defined by MGL a IM S150A.
The debris will be disposed of at: �a/Lf S1r (2119R 11,
Location ofFa My
Si Of Pc=h Appli Date
FULLY complde the following iafomimum
(PLEASE PR 4T CLEARLY)
Name ofPermitApplicant
Firm Nam%if may
Address,City R State
The above statute mgmm that debris fiom the demolition,renovation,rehab or other
ahantion of building or sbucdu a be disposed in a properly-licemed solid-waste disposal
facility as defined by MU ca S 150A,and the building pamits or licenses we to
indicate the location of the Lcility.
Cocc-m�monwuaWLpO1� frla{66aA[LJ8U6
° .Uspa�nua�a/.7edrsfrial J�cci"ALS
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600 ryw�a,�ijim-Simd
James J.Camood +tJ�a l ae, ///auae�wt� 02111
CarAussorw
Workers' Compensation Insurance MUM*
. . witisa principal place of business at:
. . ;u.,isw✓ae,s .
do hereby'ccrtify under the pains and penalties of perjury, thm
() I am an employer providing workers' compensation coverage for my cinployees working on
this job.
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me In any caFaccy
O 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation polices:
Contractor Insurance Company/Poi'tcy Number
Contractor Insurance Compasry/Policy Number
Contractor Insurance Company/Pokey Number
() 1 am a homeowner performing all the work myself.
1 wr4entana erase a copy of Ofo auxnx+►wit be for..aroea max Offee or In.eaaeaooro of ax DIA iw co.ersre ace°°ana oex Isiws,°sssare
eo.eosre y rew►ra uneer Se[tion 25A°I r1Gl 152 can ka0 w el+e:++oa+ni°n of enm►wr ernaroes eonweint d a fen d°a w41.500A0 wWw one
racers'ir..oroor►nml v q,a a chi o awde1 in the Iorm of a STOP W ORK ORD ER an°a fox of S 100.00 a am stiwt soL
Signed this , day of
._iccnseti Ftrrnmtt Building Gepa n Brat
uccnsing Ecare
Seieetmens Office
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